Presented by The Royal's Dr. Fotini Zachariades at our annual Women in Mind Conference.
She is a Clinical, Health, and
Rehabilitation Psychologist currently at the Women’s
Mental Health Program at The Royal
PTSD is a disease first introduced into the diagnostic and statistical manual of mental disorders (DSM) in 1980
With the world experiencing an unprecedented onslaught of disasters and traumas, it is imperative that health workers are aware of the disease and the factors that affect it
Crime victim are at risk for developing PTSD. Rape trauma syndrome is also known as PTSD. PTSD is not only a veterans condition. PTSD develop after experiencing a traumatic event. Traumatic events may include child abuse, child sex abuse, sexual assault, natural disasters, accidents, or combat trauma. PTSD awareness, education, and early intervention can help survivors of crime from developing PTSD, or chronic long term effects of crime victimization.
Alex's Lemonade Stand Foundation holds an annual Childhood Cancer Symposium in Philadelphia. It is designed to be an educational resource, providing families with the opportunity to learn about issues and topics of treatment and beyond, while meeting other families in a group setting. Registration is free and is open to all those touched by childhood cancer, including patients and their siblings.
Presentation by: Melissa Alderfer, PhD.
10.28.08(d): Somatoform Disorders, Factitious Disorder and MalingeringOpen.Michigan
Slideshow is from the University of Michigan Medical
School's M2 Psychiatry sequence
View additional course materials on Open.Michigan: openmi.ch/med-M2Psych
Mary T. Rourke, Ph.D., discusses how medical traumatic stress impacts the whole family. This session is part of Alex's Lemonade Stand Foundation's annual Childhood Cancer Symposium. To listen to the audio recording please visit: http://www.alexslemonade.org/campaign/symposium-childhood-cancer.
Presented by The Royal's Dr. Fotini Zachariades at our annual Women in Mind Conference.
She is a Clinical, Health, and
Rehabilitation Psychologist currently at the Women’s
Mental Health Program at The Royal
PTSD is a disease first introduced into the diagnostic and statistical manual of mental disorders (DSM) in 1980
With the world experiencing an unprecedented onslaught of disasters and traumas, it is imperative that health workers are aware of the disease and the factors that affect it
Crime victim are at risk for developing PTSD. Rape trauma syndrome is also known as PTSD. PTSD is not only a veterans condition. PTSD develop after experiencing a traumatic event. Traumatic events may include child abuse, child sex abuse, sexual assault, natural disasters, accidents, or combat trauma. PTSD awareness, education, and early intervention can help survivors of crime from developing PTSD, or chronic long term effects of crime victimization.
Alex's Lemonade Stand Foundation holds an annual Childhood Cancer Symposium in Philadelphia. It is designed to be an educational resource, providing families with the opportunity to learn about issues and topics of treatment and beyond, while meeting other families in a group setting. Registration is free and is open to all those touched by childhood cancer, including patients and their siblings.
Presentation by: Melissa Alderfer, PhD.
10.28.08(d): Somatoform Disorders, Factitious Disorder and MalingeringOpen.Michigan
Slideshow is from the University of Michigan Medical
School's M2 Psychiatry sequence
View additional course materials on Open.Michigan: openmi.ch/med-M2Psych
Mary T. Rourke, Ph.D., discusses how medical traumatic stress impacts the whole family. This session is part of Alex's Lemonade Stand Foundation's annual Childhood Cancer Symposium. To listen to the audio recording please visit: http://www.alexslemonade.org/campaign/symposium-childhood-cancer.
This presentation brings together 3 currents in my approach to treating pediatric epilepsy: a recognition of the importance of epilepsy comorbidities, partnering with families in patient assessment and decision making, and creative use of informatics/EHR's to gather information about clinical aspects of epilepsy. A presentation to the Missouri Valley Child Neurology Colloquium, March 2012.
“Teen Depression and Suicide,”
South Portland, Maine; April 26, 2005
Suicide Conference, Maine Suicide Prevention Program.
*Learn clinical presentation of adolescent depression
*Learn course and prognosis of pediatric depression
*Learn treatment of pediatric depression
*Discuss controversy of antidepressant medications in youth and suicidality
Do Adolescents with Eating Disorders Ever Get Well?Dr David Herzog
Dr. David Herzog presents a slideshow regarding adolescents and their struggle with eating disorders. Do they ever get better and move past their eating disorders?
this is the detailed contents of various steps in nursing process, make use of my content.regards.R.BABU.
PROF & HOD,THE OXFORD COLLEGE OF NURSING -BANGALORE
1
6
Assignment template
Subjective Section
Chief complainant
The patient starts by saying, "I can't stop crying, all the time." The patient complains that since she gave birth to her child two months ago, she has been experiencing mood disorders and difficulties falling asleep even after the baby is already asleep. She complains that especially when the baby cries, she loses her appetite and is not comfortable with her new body shape and size. She says nothing interests her, even writing, which was one of the things she loved before she gave birth. She does not want to contact her friends, and everything seems to be upsetting her.
History of present illness (HPI)
L.T is a 32-year-old black female who resents for psychiatric evaluation due to mood depression. The patient has not been prescribed any psychotropic drugs recently.
Past psychiatric history
The patient has never been examined or treated for any mental disorders in the past. Recently she was hospitalized for a standard childbirth procedure.
Medication trials and current medication
She has not tried any medications in the past, neither is she under any medication currently.
Psychotherapy or previous psychiatric diagnosis
The patient has no history of psychiatric illness and has not been diagnosed or treated with any mental health disorder.
Pertinent substance use, social, and medical history
The patient denies any use of alcohol or cases of drug abuse in the family. Although she says that her uncle was not an opioid abuser, he committed suicide using GSW. She is married and currently lives with her husband with their two kids. She has been working in the retail business for the past five years, but currently, she is a housewife. The patient grew up with her sister together with her both parents. She has been diagnosed with hypertension recently, and she is taking drugs labelled as labetalol 100mg for HTN, which she says that she sometimes forgets to take them. The patient has no legal history or any issues related to violence.
Allergies
L.T is allergic to codeine. She gave birth two months ago, which automatically means that she is lactating. Currently, she is not using any form of contraceptive, and she has had no desire for sex since she gave birth.
ROS
General: No weight loss, fatigue or chills experienced by the patient.
HEET: Her vision is the same no issues of double vision or jaundice. Her ears, nose and throat are okay.
Skin: Her skin has not changed either is she having rashes.
Cardiovascular: No chest discomfort or pains.
Respiratory: She is not coughing or producing sputum, implying her respiratory is fine.
Gastrointestinal: She has eventually lost her appetite and wants to lose weight, although she is not vomiting or feeling abdominal pain.
Genitourinary: The urine colour or odour has not changed, and she is not experiencing any burns during urination. No headaches, no back or joint pains.
Hematologic: No bleeding realized or enlarged nodes.
Endocri ...
1
6
Assignment template
Subjective Section
Chief complainant
The patient starts by saying, "I can't stop crying, all the time." The patient complains that since she gave birth to her child two months ago, she has been experiencing mood disorders and difficulties falling asleep even after the baby is already asleep. She complains that especially when the baby cries, she loses her appetite and is not comfortable with her new body shape and size. She says nothing interests her, even writing, which was one of the things she loved before she gave birth. She does not want to contact her friends, and everything seems to be upsetting her.
History of present illness (HPI)
L.T is a 32-year-old black female who resents for psychiatric evaluation due to mood depression. The patient has not been prescribed any psychotropic drugs recently.
Past psychiatric history
The patient has never been examined or treated for any mental disorders in the past. Recently she was hospitalized for a standard childbirth procedure.
Medication trials and current medication
She has not tried any medications in the past, neither is she under any medication currently.
Psychotherapy or previous psychiatric diagnosis
The patient has no history of psychiatric illness and has not been diagnosed or treated with any mental health disorder.
Pertinent substance use, social, and medical history
The patient denies any use of alcohol or cases of drug abuse in the family. Although she says that her uncle was not an opioid abuser, he committed suicide using GSW. She is married and currently lives with her husband with their two kids. She has been working in the retail business for the past five years, but currently, she is a housewife. The patient grew up with her sister together with her both parents. She has been diagnosed with hypertension recently, and she is taking drugs labelled as labetalol 100mg for HTN, which she says that she sometimes forgets to take them. The patient has no legal history or any issues related to violence.
Allergies
L.T is allergic to codeine. She gave birth two months ago, which automatically means that she is lactating. Currently, she is not using any form of contraceptive, and she has had no desire for sex since she gave birth.
ROS
General: No weight loss, fatigue or chills experienced by the patient.
HEET: Her vision is the same no issues of double vision or jaundice. Her ears, nose and throat are okay.
Skin: Her skin has not changed either is she having rashes.
Cardiovascular: No chest discomfort or pains.
Respiratory: She is not coughing or producing sputum, implying her respiratory is fine.
Gastrointestinal: She has eventually lost her appetite and wants to lose weight, although she is not vomiting or feeling abdominal pain.
Genitourinary: The urine colour or odour has not changed, and she is not experiencing any burns during urination. No headaches, no back or joint pains.
Hematologic: No bleeding realized or enlarged nodes.
Endocri ...
Clinical Assessment of Children and Adolescents with DepressionCarlo Carandang
“Clinical Assessment of Children and Adolescents with Depression,”
Halifax, Nova Scotia, Canada; October 1, 2008
Pediatric Grand Rounds, IWK Health Centre
*Although the core symptoms of depression are similar across the life span, developmental differences exist and should be taken into account in the assessment
*With increasing age, there generally is an increase in melancholic symptoms, delusions, substance abuse, and suicidal ideation/attempts.
*In contrast, younger children tend to have more somatic sxs, separation anxiety, behavior problems, temper tantrums, and hallucinations
*Direct interviews with children and adolescents are critical because parents and teachers may not be aware of the youth’s depressive symptoms
*Discrepant information between parents and their children should be solve in a cordial and non judgmental way
*Assessment of suicidal and homicidal ideation and behaviors is mandatory
*The interview process and screening questions utilized by research interviews such as the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime Version (KSADS-PL) can be useful
*Detection and diagnosis can be enhanced by available parent and child self-report measures
11. Identifying the Elements of the Limitations & ImplicationsGo tBenitoSumpter862
11. Identifying the Elements of the Limitations & Implications
Go to the Limitations/Implications section(s) and identify the limitations of the study and how those limitations impacted the whole study.
12. Identifying the Elements of the Conclusion Section
Go to the Conclusion section and identify the conclusive statements of the study and the recommendations made for future research.
POST # 1 EDITHA
When assessing an adolescent with bipolar disorder, what are some of the diagnostic and treatment challenges the clinician might face?
Bipolar disorder is a serious mental health disorder that is often first diagnosed during young adulthood or adolescence. Symptoms of the illness, however, also can appear in early childhood. Although once thought rare in children, diagnosis of bipolar disorder in children has significantly increased over the last decade (Papolos & Bronsteen, 2018). Despite the increased diagnosis of bipolar disorder in children, assessment and diagnosis remain challenging and controversial. This is, in part, because of the lack of research on this disorder in children and adolescents and the growing recognition that the disease can present differently in children from how it presents in adults (AACAP, 2019). Over the years, more attention has focused on the unique presentation of bipolar disorder in the young that has introduced new ways of looking at this disease and assessing it in children.
The importance of identifying the presence of bipolar disease at an early age is highlighted by data showing that adults in whom bipolar disease started at an early age have a more severe course of the illness compared with adult-onset disease. Early-onset disease is associated with a higher risk of suicide; severe mood lability and polarity; lower quality of life and greater functional impairment; higher rates of comorbidity; and a higher risk of substance use disorders compared with adult-onset disease (Papolos & Bronsteen, 2018). Although some children meet the criteria established for adults categorized in the DSM-5, many children fall outside these classical categories, and diagnosis in these children is particularly challenging and difficult (APA, 2013). For these children, additional information beyond what is provided in the DSM may help make an accurate diagnosis which causes increased challenges in assessment and diagnosis.
References
Papolos, D, & Bronsteen A. (2018) bipolar disorder in children: assessment in general pediatric practice. Curr Opin Pediatr, 25(3):419-426.
American Academy of Child and Adolescent Psychiatry (AACAP). (2019) bipolar disorder: Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents.
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association.
RESEARCH ARTICLE
Association of suicidal behavior with exposure
to suicide and suicide attempt: A systematic
...
11. Identifying the Elements of the Limitations & ImplicationsGo tSantosConleyha
11. Identifying the Elements of the Limitations & Implications
Go to the Limitations/Implications section(s) and identify the limitations of the study and how those limitations impacted the whole study.
12. Identifying the Elements of the Conclusion Section
Go to the Conclusion section and identify the conclusive statements of the study and the recommendations made for future research.
POST # 1 EDITHA
When assessing an adolescent with bipolar disorder, what are some of the diagnostic and treatment challenges the clinician might face?
Bipolar disorder is a serious mental health disorder that is often first diagnosed during young adulthood or adolescence. Symptoms of the illness, however, also can appear in early childhood. Although once thought rare in children, diagnosis of bipolar disorder in children has significantly increased over the last decade (Papolos & Bronsteen, 2018). Despite the increased diagnosis of bipolar disorder in children, assessment and diagnosis remain challenging and controversial. This is, in part, because of the lack of research on this disorder in children and adolescents and the growing recognition that the disease can present differently in children from how it presents in adults (AACAP, 2019). Over the years, more attention has focused on the unique presentation of bipolar disorder in the young that has introduced new ways of looking at this disease and assessing it in children.
The importance of identifying the presence of bipolar disease at an early age is highlighted by data showing that adults in whom bipolar disease started at an early age have a more severe course of the illness compared with adult-onset disease. Early-onset disease is associated with a higher risk of suicide; severe mood lability and polarity; lower quality of life and greater functional impairment; higher rates of comorbidity; and a higher risk of substance use disorders compared with adult-onset disease (Papolos & Bronsteen, 2018). Although some children meet the criteria established for adults categorized in the DSM-5, many children fall outside these classical categories, and diagnosis in these children is particularly challenging and difficult (APA, 2013). For these children, additional information beyond what is provided in the DSM may help make an accurate diagnosis which causes increased challenges in assessment and diagnosis.
References
Papolos, D, & Bronsteen A. (2018) bipolar disorder in children: assessment in general pediatric practice. Curr Opin Pediatr, 25(3):419-426.
American Academy of Child and Adolescent Psychiatry (AACAP). (2019) bipolar disorder: Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents.
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association.
RESEARCH ARTICLE
Association of suicidal behavior with exposure
to suicide and suicide attempt: A systematic
...
Grand Rounds presentation by Cathy Humphreys, Gabriel Ronen, Olaf Kraus de Camargo, Peter Rosenbaum and Sara Patterson about how to integrate concepts and frameworks of Narrative Medicine, Patient Reported Outcomes and the ICF framework in order to provide personalized healthcare to children and their families.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
2. Outline of Talk
WHAT
Concept and history of early intervention for
psychiatric disorders
Its application to eating disorders
WHY
Importance of early intervention in anorexia
nervosa (AN)
HOW
Early Case Identification
○ Using multiple informant methods
Early Treatment
○ An adaptation of FBT for prodromal AN
3. Support and Disclosures
K23MH074506: Early Identification and
Treatment of Anorexia Nervosa
R21HD057394: Parent-Based
Treatment for Pediatric Overweight
NIFA/USDA 2011-67002-30086:
Optimal Defaults and Parent
Empowerment in the Prevention of Early
Childhood Obesity: A Community
Center-Based Pilot Study
No other financial disclosures
4.
5. Continuum of Prevention to
Treatment
Relapse Prevention
Successfully Treated Individuals
Treatment
Early Identification
Diagnosed Individuals
Early Treatment
Clinically Significant Indicated Prevention
but Not (Yet?) High-Risk Individuals
Diagnostic
Presentations Selective Prevention
At-Risk Individuals
Universal Prevention
General Population
6. History of Early Intervention in
Psychiatry
Originated in the study and treatment of
psychosis
Impending syndrome severe enough to warrant “risking”
treating false positive cases
Identifiable prodrome
Emerging symptom profile is clinically significant in its
own right
Promising results
○ Reduction of extant symptoms
○ Prevention of conversion to full syndrome
○ Fewer hospitalizations
Bipolar Disorder
Autism
7. Early Intervention in AN:
Do the Same Criteria Apply?
Impending syndrome severe enough to
warrant “risking” treating false positive
cases?
Identifiable prodrome?
Emerging symptom profile is clinically
significant in its own right?
Promising results?
○ Reduction of extant symptoms
○ Prevention of conversion to full syndrome
○ Fewer hospitalizations
8. How to distinguish between
indicated prevention vs. early
treatment in eating disorders?
When specific risk factors (vulnerability
for progression to the full disorder) are
exhibited, targeted prevention is
appropriate
Once symptoms diagnostically essential
for the full disorder are exhibited, the
prodrome is conceptualized and early
treatment is indicated
Stice et al., 2010
9.
10. Early identification and treatment of
AN
Positively skewed prevalence and onset
distributions of AN across age
Early identification and treatment efforts
have therefore appropriately targeted
children and adolescents
Such efforts appear to have a positive
prognostic impact on the course of
illness
The optimal point of their application
remains unclear
11. Prevention of AN in high risk
youth
New, AN-spectrum presentations are
associated with significant clinical
severity and medical risk, equivalent to
levels seen in AN
Such presentations may reflect a
disorder in evolution (prodrome), rather
than a stable subsyndromal state or
transient phase
Identifying and treating the AN prodrome
could prevent conversion to AN, which is
notoriously refractory to treatment
12. Identifying the AN
SAN
Prodrome within a Subsyndrome ~
Syndrome
Working Model of Severity
Subsyndromal AN Risk
Subsyndrome = Subsyndrome =
Prodrome Subsyndrome = Subsyndrome =
Syndrome
(Disorder in Subsyndrome Partial Remission
(Early Caseness)
Evolution) (Atypical AN) (Former AN)
Age-Specific
Limitations of
Manifestations
Current
Of Full Diagnosis
Assessment Stable/Chronic Transient
Not Accounted
Methods
For in DSM-IV
Le Grange & Loeb, 2007
13. Differentiation of prodromal vs.
atypical AN: Pilot data
Twenty-seven adolescents with SAN
SAN defined as:
Meeting 2 of the 4 DSM-IV diagnostic criteria for AN
If Criterion A is not met, participants must have engaged in dietary
restriction leading weight < 100% expected, in combination with 2-3
additional criteria
Never met criteria for full AN
Qualitatively subtyped sample as follows:
High Risk for Conversion to AN (Prodromal AN)
○ Steady worsening of symptoms from point at which symptoms became
clinically significant
High Risk for Chronic SAN (Atypical AN)
○ Following a period of symptom progression, symptoms have stabilized
for a period of 3+ months
14. Prodromal vs. Atypical cont.
Variable Prodromal AN Atypical AN t (df=25) Sig (2-tailed)
(n=13) (n=14)
Mean (SD) Mean (SD)
Age 14.54 (1.81) 14.57 (1.83) -.045 .963
Duration of 4.31 (2.78) 25.21 (18.37) -4.06 .000
Illness (months)
%IBW 88.75 (7.31) 82.48 (6.81) 2.31 .030
EDE Restraint 3.34 (1.74) 1.56 (1.52) 2.84 .009
EDE Shape 3.16 (1.72) 1.55 (1.64) 2.50 .020
Concern
EDE Weight 2.84 (1.82) 1.64 (1.52) 1.86 .075
Concern
EDE Eating 2.19 (1.72) 0.92 (1.21) 2.24 .035
Concern
Sum (max=16) 14.00 (6.61) 7.93 (6.89) 2.33 .028
EDE Dx Items
15. Prodromal vs. Atypical cont.
Differences between subtypes suggest
that those patients who appear to be at
higher risk for developing AN by virtue of
a linear and often steep symptom
progression in fact exhibit more AN-like
psychopathology than their more chronic
and stable SAN counterparts
Unclear whether intervention strategies
need to be tailored accordingly
16.
17.
18. Early Intervention is Predicated
on Case Identification…
…which in turn is challenged by:
The ego-syntonic nature of eating disorders, resulting in
denial and minimization
Developmentally insensitive diagnostic criteria
Normal adolescent development, which can obfuscate
awareness of an emerging eating disorder because of
shared features
○ preoccupation with appearance
○ individuation from parental support systems
○ expression of strong attitudes
○ mood lability
Eating disorders can present with the strong will
and affect of typical adolescence, resulting in
alienation from family members and increased
space for the disorder to intensify.
19. Potential Sources of Case
Identification for Multiple Informant
Methods
Patients
Parents
Physicians (e.g., pediatricians)
Schools
Teachers
Guidance Counselors
Adminstrators
20. Patient vs. Parents as Informants
Patients Parents
Deny Report
Minimize observable, behaviora
Often lack insight l indicators of
psychological features
Fear implications of their of the illness
symptom Consider information
endorsement reported by reliable
third parties, such as
the housekeeper or
the child’s
siblings, friends, or
teachers
Report “clues” to
behavioral
symptoms, even et al., 2011
Loeb
secretive ones
21. Parents as informants in case
identification: Examples (Loeb et al, 2011)
Patients Parents
I’m not bingeing. I find bags of junk food hidden in
her room.
I’m not vomiting. She runs to the bathroom right
after meals, and our
housekeeper finds vomit
residue on the toilet.
I’m getting my period regularly. I haven’t bought sanitary products
for her in 6 months.
I’m an athlete. I’m not exercising Her coach says she trains
to lose weight. beyond what her teammates
do.
I’m fine with my body. She wears only baggy clothes.
I’m fine with my weight. She weighs herself several times
a day.
I’m not scared of gaining weight. She won’t eat more than 500 kcal
per day.
22. Eating Disorder Examination
(EDE): Direct patient report
example
FEAR OF WEIGHT GAIN (Diagnostic item, Shape Concern subscale)
*Over the past four weeks have you been afraid that you might gain weight?
[With participants who have recently gained weight the question may rephrased as "..... have you been afraid that you
might gain more weight".]
How afraid have you been?
[Rate the number of days on which a definite fear (common usage) has been present. Exclude reactions to actual weight
gain.]
0 - No definite fear of weight gain
1 - Definite fear of weight gain on 1 to 5 days
2 - Definite fear of weight gain on less than half the days (6 to 12 days)
3 - Definite fear of weight gain on half the days (13 to 15 days)
4 - Definite fear of weight gain on more than half the days (16 to 22 days)
5 - Definite fear of weight gain almost every day (23 to 27 days)
6 - Definite fear of weight gain every day [ ]
[With participants whose weight might make them eligible for the diagnosis of anorexia nervosa, ask about each of the
preceding two months. Rate 9 if not asked.]
month 2 [ ]
month 3 [ ]
Cooper & Fairburn, 1987; Fairburn & Cooper, 1993; Fairburn, Cooper, & O’Connor, 2008
23. EDE – Parent Version
(Loeb, 2005)
FEAR OF WEIGHT GAIN (Diagnostic item, Shape Concern subscale)
*Over the past four weeks has your child expressed a fear of gaining weight or becoming fat?
....If yes:
What exactly has s/he said to indicate this?
....Re-rate this item taking into account behavioural evidence of fear of weight gain.
For children who are underweight or whom parents or doctors are concerned have lost too much weight: Have
you tried to encourage your child to eat more in order to gain weight? How has s/he responded? Has
s/he rejected advice or prescriptions (from you, doctors, or other professionals) to increase his/her
weight? In addition to taking notes, mark whether or not there was a negative response to efforts to increase
the child’s food consumption or weight by circling yes or no:
[Yes/No]
Has s/he refused attempts (by you, doctors, or other professionals) to increase his/her weight?
[Yes/No]
If yes:
…by passive resistance (e.g., by simply refusing to eat)? [Yes/No]
…and/or by active resistance such as…? [Yes/No]
…yelling? [Yes/No]
…throwing a tantrum? [Yes/No]
…throwing food or dishes? [Yes/No]
…running away? [Yes/No]
…threatening to hurt him/herself if made to eat? [Yes/No]
…other (specify)?.....
24. Parents as informants in case
identification: Data
Kappas for Parent-Child Agreement on the EDE and P-EDE DSM-IV Diagnostic
Criteria for AN
____________________________________________________________________
DSM-IV Criterion A Criterion B Criterion C Criterion D
Criteria for
AN
____________________________________________________________________
Cohen’s
Kappa .307* .210 .368** .795**
____________________________________________________________________
*p < .05 **p < .01
E.g., for Fear of Weight Gain, parents (+ behavioral indicators) can increase
diagnostic symptom identification by up to 50%
Loeb et al., 2009
25.
26. FBT for SAN:
Modifications to the Foundation Approach I
Dual focus of risk reduction (prophylaxis of AN) and the
resolution of extant symptoms (treatment)
The risks of conversion to AN are emphasized, while
noting that science cannot yet predict which cases are
truly prodromal vs. misdiagnosed vs. atypical vs.
transient
The clinical severity of SAN is emphasized in its own
right, addressing the general and the specific:
The functional impairment associated with the overall presentation
The dangers of each individual symptom
Attention to a wider range of developmental stages to
encompass childhood cases. While AN typically onsets
in mid-late adolescence, prodromal AN by definition
precedes this.
27. Modifications to the Foundation Approach II
Modifications to the language of the treatment to
emphasize risk, e.g.,
Your daughter is at the precipice of a deadly disorder
The eating disorder is like an octopus whose tentacles have
just taken hold and are squeezing harder and harder over
time
Modifications to the family picnic meal (session two)
instructions to address the variability in SAN
presentation:
In deciding what to bring for your daughter to eat, consider
her degree of weight loss and how you want to help her eat
normal, healthy amounts of food again. Please include at
least one food she used to like but has stopped eating.
Quality of food eaten (e.g., a forbidden food) may be as
important as quantity (“one more bite”)
28. Modifications to the Foundation Approach
III
A greater emphasis on the regulation of eating
patterns and the incorporation of a full range of
foods in the child or adolescent’s diet, especially
for adolescents who have lost significant weight
but do not yet meet the weight cutoff for AN
Psychoeducation regarding the role of excessive
dietary restraint in the development and
maintenance of eating disorders, and the
ineffectiveness of extreme restriction and eating
disorder behaviors in achieving and maintaining a
healthy weight range
Emphasis on deriving a positive self-concept from
domains other than body image
29. Modifications to the Foundation Approach
IV
The prescription of regular family meals at
home
While research on the negative correlation between
family meals and eating disorders does not tease
apart self-selection from effect, common sense
dictates that family meals at least provide the
following:
○ An opportunity to observe and correct unhealthy eating
habits in offspring
○ An opportunity for parents to model healthy, non-restrictive
eating habits
○ A forum in which to identify and discuss stressors that may
precipitate or exacerbate the onset of an eating disorder
30. Modifications to the Foundation Approach
V
It is important that parents do not explicitly
exhibit behaviors and attitudes consistent
with an eating disorder
The difference between AN and other
presentations (above-normative levels of
discontent regarding shape/weight, fad dieting)
is sufficiently stark that the illness offers a clear
target. With SAN, the boundaries between the
eating disorder and non-disordered but
unhealthy behaviors and attitudes may be more
diffuse from the family’s perspective, and
especially from the child’s perspective
Given data on genetic risk for AN, for some
cases, treatment must attempt reshape a
genetically influenced environment
32. FBT RCT for prevention of AN in
high-risk adolescents
Sample: 60 children and adolescents with emerging
(prodromal) or atypical AN
Two study interventions:
FBT modified for prevention
Individual supportive psychotherapy
Using a partially randomized preference design
Testing PEDE as an informant-based assessment
tool to complement direct evaluation
Two primary questions:
Is FBT effective for reduction of extant symptoms and
prophylaxis of AN?
Are these cases in fact child/adolescent manifestations of full
AN?
Supported by 1 K23 MH074506-01
34. Preliminary FBT only
findings
N=45 %IBW
Mean (SD) age: 100
13.3 (2.1)
83.3% female 95
89.2% Caucasian
85% from intact 90
families
89% stabilized or 85
improved
11% converted to 80
AN Baseline EOT
35. Case Study: “Bella”
Seventeen year old monozygotic twin
Twin sister unafflicted
Two-parent household
Identified and referred by general
therapist, who was treating the patient for
anxiety and perfectionism
Four month history of weight loss, from 102%
IBW to 89.5% IBW
Categorically denied a fear of weight gain, but
admitted to regarding her body as fat, her
thighs as “huge” and her hips as “wide”
Missed two periods
Loeb et al., 2009
38. Parents are essential in the
Diagnosis
Prevention
Treatment
of child and adolescent eating disorders
Early Identification
Informants of direct symptom expression and
behavioral indicators
Early Treatment
Agents of change with FBT principles and
techniques